Quality Improvement Initiative Issue Paper



Quality Improvement Initiative Issue PaperQuitline Referral Systems DRAFTQuitlines have the opportunity to link their services to providers in the healthcare delivery system and patients who use tobacco. As such, they can potentially play an important role in health system changes that support cessation, especially in today’s changing healthcare landscape.While 50 states and 10 provinces currently support fax-referral by providers to their quitline, the variation in services among them is substantial. With the launch of the U.S. federal government’s Meaningful Use Initiative, electronic referral is being explored and established by a growing number of quitlines. There has been limited research on the purpose and design of referral programs, and to date there has been no systematic attempt to document operational practices or standards for fax or electronic referral systems linking providers and their patients to the quitline. Referral systems have the potential to be a powerful tool for quitlines, as a complement to traditional outreach using advertising. Referral systems are important to health care reform, as they better align public health initiatives with the health care community. Referral systems have been proven successful in driving quitline enrollment and are cost-effective and self-sustaining, once systems have been implemented.The purpose of this paper is to explore the current landscape of quitline fax and electronic referral systems with healthcare and other providers and to examine in detail the critical operational and outcome-related components of these referral systems. It is recognized that referral systems and objectives are different between the U.S. and Canada, and this paper reflects the U.S. experience moreso than Canada. The paper will define types of referral systems, discuss essential operational components and key service quality issues, followed by recommendations on key systems changes based on the evidence available or supported by current practice. The primary audience for the paper is quitline funders, service providers, healthcare providers and public health professionals. NAQC has formed a workgroup for developing more technical schematics and standards for electronic referral systems. Its recommendations will follow the release of this issue paper.SECTION ONE: BACKGROUNDPrevalence and ImpactTobacco use prevalence has significantly decreased with policy, cessation and education initiatives; however, we have now reached a relative plateau with 19.3% use in the U.S. (1) and 17% use in Canada. (2) In the U.S., an estimated 443,000 individuals each year die of preventable smoking-related deaths. (1)We know that most tobacco users want to quit; in the U.S., data from the 2010 National Health Interview Survey showed that 68.8% adult smokers wanted to stop smoking and 52.4% had tried to quit smoking in the past year. However, 68.3% of the smokers who tried to quit did so without using evidence-based cessation counseling or medications. (3) It is critical that evidence-based cessation services be made available and accessible to all tobacco users, regardless of type of product use, level of addiction and demographic characteristics. A comprehensive array of services provides opportunity to offer assistance to a large number of tobacco users. While valuable face-to-face programming is preferred by some; its reach is relatively low due to limited resources and accessibility. Quitlines have shown the capacity to provide aide to large numbers of tobacco users with relative ease of access to behavioral and pharmacologic support. They have consistently shown both effectiveness and relative cost efficiency in assisting tobacco users to quit. Both quitline promotional reach and treatment reach, however, remain short of desired goals, with elasticity often related to available service and marketing resources. (4) The latter are often limited and additional consistent engagement strategies are needed to increase the impact of quitline services. Provider Referrals in PracticeSeventy percent of smokers interact with their medical providers over the course of a year, providing teachable opportunities to assist patients, many with fears and concerns about tobacco use. (5) Because tobacco dependence is a chronic condition that often requires repeated intervention, the U.S. Department of Health and Human Services Clinical Practice Guideline, Treating Tobacco Use and Dependence, 2008 Update recommends that the 5As (Ask, Advise, Assess, Assist, and Arrange) be implemented for every patient who uses tobacco at every clinic visit (6) However, only 48.3% of U.S. smokers in 2010 said they had been advised by a health professional to quit. (3) For patients visiting their primary care physicians, 32% are preparing or taking action to quit, while an additional 43% are contemplating quitting. (7) A recent CDC study found that the 5A recommendation is not routinely followed in clinical practice. Although tobacco use screening occurred during the majority of adult visits to outpatient physician offices, among patients who were identified as current tobacco users (62.7%), only 20.9% received tobacco cessation counseling and 7.6% received tobacco cessation medication. (8) Unfortunately, competing health priorities during a brief well or sick visit often supersede those of tobacco cessation and reimbursement has been limited. We know that systematic identification of smoking status increases clinicians’ delivery of advice and counseling. Smokers who receive advice to quit from their doctor are 30% more likely to quit than those who do not receive advice. (6) It is essential that providers have evidence-based referral services available to assist their patients beyond the limited intervention they can deliver in the office visit. Although in some cases, face-to-face health system or community resources are available, it is likely they are limited, if available at all. Quitlines, presently in all U.S. states and Canadian provinces, the District of Columbia, Puerto Rico and Guam, provide the infrastructure for service to a large number of tobacco users. Whether publicly or privately funded, or a combination thereof, most tobacco users are able to receive free counseling and many are able to receive pharmacotherapy for a period of time. (4) Quitlines, however, are still well short of service goals. The 2011 Annual Survey of Quitlines revealed that only 1.15% of U.S. residents and 0.30% of Canadian residences are receiving evidence based services through their respective quitlines. (4)Providers have been encouraged to refer their patients to quitlines using adapted 5A’s models of Ask/Advise/Refer or Ask/Advise/Assess/Refer.?The Smoking Cessation Leadership Center has long promoted the Ask/Advise/Refer Model through relationships with many professional organizations. (9) It is important to remember that this model may be considered by some to include assessment of readiness to quit, even though it is not explicitly stated. Many tobacco users have connected with quitlines after providers have encouraged them to do so, starting years before fax referrals were implemented. In California, provider-referred clients have represented a steadily increasing share of participants - 41% of 40,000+ unique individuals in CY2012, of which 90% were from indirect referrals to call the quitline and 10% from provider fax referrals.? In contrast, media accounted for only 31% of participants in the same period.? Indirect referrals require less effort by clinic and quitline staff, while provider fax referrals offer the benefit of a feedback loop on patient engagement. In California, fax referrals were ten times more likely than indirect referrals to result in an initial patient contact to encourage enrollment.?(10) Referral programs have been implemented in many states and provinces and their use has grown substantially. Although there are 3.8 times as many direct calls from tobacco users as referrals in the U.S., Canadian quitlines receive 1.75 times as many referrals as direct calls.In FY11, in the U.S. there were 97,504 fax referrals, 82.8% of all direct referrals. One-thousand, or 0.8 %, were EMR referrals (tied directly to medical systems) and 19,204 or 1.6% were other types of referrals. In Canada, 8,888 or 40.8% were fax referrals, 1,515 or 7.0% were EMR referrals, and 11,370 or 52.2% were other types of referrals (e.g., web referrals, “click to call,” online ads, etc.). (4)In 2011, the vast majority of U.S. and Canadian quitlines offered fax referral methods to providers while only 34% of U.S. and 25% of Canadian quitlines offered email or online referrals. Seventeen percent of U.S. quitlines, through pilot programs, and no Canadian quitlines offered electronic medical record (EMR) referrals with electronic submission. Canadian quitlines allowed referrals for tobacco users in the contemplation through maintenance stages of change while more U.S. quitlines preferred that tobacco users at least be in the preparation stage of quitting. (4)Consistent increases in reach have been realized in states and healthcare systems that have instituted direct referral systems with providers. For example, in Wisconsin, an active academic detailing system to continually refresh providers’ awareness of the state quitline and direct referral mechanism has been able to achieve sustainable quitline enrollment without a statewide marketing campaign. Various methods have included presenting at grand rounds, professional meetings and other clinical events; cultivating on-site “champions”; and training all members of the healthcare team. (11) Massachusetts’ provider referrals now account for approximately 80% of total quitline utilization, with results attributed to various promotion campaigns, technical assistance and training, and implementation of eReferrals. (12) Through better education and feedback reporting, providers and quitlines are able to partner in providing evidence-based comprehensive tobacco use treatment to address the number one preventable contributor to disease and significantly improve the health of their patients. Healthcare Reform InitiativesMedicare and Medicaid U.S. health care reform initiatives will bolster access to and availability of cessation services. The 2010 Patient Protection and Affordable Care Act (ACA) substantially expands coverage of smoking cessation treatments. Effective October 1, 2010, state Medicaid programs were required to provide cessation coverage to pregnant enrollees with no cost sharing. The legislation also bars state Medicaid programs from excluding FDA-approved cessation medications, including over-the-counter medications, from Medicaid drug coverage, effective January 1, 2014, and requires non-grandfathered private health plans to offer cessation coverage without cost sharing, effective September 23, 2010. (3) The Centers for Medicare and Medicaid Services (CMS), in a letter to State Medicaid Directors on June 24, 2011, provided guidance on tobacco cessation quitlines as an allowable Medicaid administrative cost expenditure. This decision allows states to claim the 50 percent federal administrative match rate for quitline services to Medicaid beneficiaries. (12) CMS has also recently added reimbursement for face-to-face tobacco interventions for Medicare patients with Part B coverage. Eligible patients include those who use tobacco and have a disease or adverse health effect linked to tobacco use. . A cessation counseling attempt occurs when a qualified physician or other Medicare-recognized practitioner determines that a beneficiary meets the eligibility requirements and initiates treatment with a cessation counseling attempt. For example, if the ask-advise-refer process requires more than 3 minutes, it qualifies as a counseling session. Referring patients to the quitline counts, if enough time is spent explaining the rationale for quitting and how the quitlines operate. Providers can bill for counseling session of >3 to 10 minutes, or for 10+ minutes. Counseling of 3 minutes or less is included as part of the visit for evaluation and management and not separately billable. Coverage for Medicare recipients without Part B coverage or inpatients and asymptomatic for conditions related to tobacco use is also available under the umbrella of preventive services and exempt from any deductible and coinsurance. In many states, some payment is available for Medicaid recipients who undergo face-to-face individual tobacco treatment counseling. (13) The ACA includes tobacco dependence as a core required outcome measure for healthcare systems.Meaningful Use of Certified EHRsThe Health Information Technology for Economic and Clinical Health (HITECH) Act, included as part of the The American Recovery and Reinvestment Act of 2009 (ARRA), is intended to accelerate the adoption of electronic health records (EHR) by providers. The HITECH Act created financial incentives for hospitals and health care providers (referred to in the Act as “eligible professionals” or “EPs”) to adopt, implement, and demonstrate meaningful use of certified electronic health record (EHR) technology. Two sets of regulations govern meaningful use, one that instructs hospitals, physicians and other care providers on how to earn incentive payments by using an EHR certified for meaningful use (Medicare and Medicaid Programs; Electronic Health Record Incentive ProgramStage 1), and one that provides EHR vendors with the criteria required to become a certified EHR (Health Information Technology: Initial Set of Standards, Implementation Specifications, and Certification Criteria for Electronic Health Record Technology). The meaningful use program is being rolled out in three stages. Stage I of meaningful use is effective for calendar years 2012 and 2013. Stages II and III will add additional requirements, and are being rolled out in 2014 and after. Health care providers must meet a series of objectives (which are different for hospitals versus eligible professionals) in order to receive their financial incentives. Several incentives in Stage I address tobacco screening and counseling, and comments provided by the tobacco cessation community seek to add additional components that will strengthen the referral link to public quitlines. (15) Outpatient and Inpatient Tobacco Core Objective: Record Smoking StatusStage 1 (Required) 2011 -2012Stage 2 (Recommended) 2014Stage 3 (Open for Public Comment)- Rulemaking 2016Data capture and sharingAdvance clinical processesImproved outcomesObjectiveRecord smoking status for patients 13 years and olderMeasureMore than 50% of all unique patients 13 years old or older seen by the EP have smoking status recorded as structured data.More that 80% of all unique patients 13 years old or older seen by the EP have smoking status recorded as structured dataOutpatient Tobacco Clinical Quality Measure (CQM)Stage 1 Measure Number (Required) Stage 1 Measure Stage 2 Measure Number (Recommended - “if representative of their clinical practice and patient population.”) Stage 2 Measure National Quality Forum (NQF) 0028 The percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received tobacco cessation counseling intervention if identified as a tobacco user The percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received tobacco cessation counseling intervention if identified as a tobacco userThe percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received tobacco cessation counseling intervention if identified as a tobacco user Other Clinical Quality MeasuresOther recent measures will impact the provision of tobacco treatment during inpatient hospitalization with extension to the post-discharge period. The Joint Commission’s new Tobacco Cessation Performance Measure-Set, effective January 1, 2012, requires that hospitals identify and document the tobacco-use status of all admitted patients, provide both evidence-based cessation counseling and medication during hospitalization for all identified tobacco users (in the absence of contraindications or patient refusal), provide a referral at discharge for evidence-based cessation counseling and a prescription for cessation medication (in the absence of contraindications or patient refusal), and document tobacco-use status approximately 30 days after discharge. However, its adoption is optional since accredited hospitals are required to report on only 4 of the 14 available sets of performance measures. (5)In addition, the National Quality Forum is considering the adoption of the new Joint Commission tobacco-use standard, and CMS has added the treatment of tobacco dependence as a topic for potential regulation in 2013; such regulation could link the documentation of consistent delivery of tobacco-dependence treatment in health care settings to reimbursement. (5)The Million Hearts initiative of the U.S. Department of Health and Human Services will support these and other efforts directed at smoking prevention and cessation in communities and clinical systems. Its goal is to prevent one million heart attacks and strokes over the next 5 years by improving access to care; focusing on improved care through use of the ABCS (aspirin therapy, blood pressure control, cholesterol management, and smoking cessation); increasing public awareness about risk factors; promoting healthier behaviors and environments; and enhancing surveillance and monitoring. Million Hearts incorporates technological advances occurring in the clinical setting (e.g., health information technology development and linkages with electronic medical records), modifications in healthcare coverage and reimbursement, and comprehensive environmental and policy initiatives. (16) The National Committee for Quality Assurance’s (NCQA) Patient-Centered Medical Home program also provides improved infrastructure to impact tobacco use by facilitating partnerships between patients and their personal physicians while working in teams and coordinating and tracking care over time. Registries, information technology, health information exchange and other means help to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner. (17) Current NCQA core tobacco use measurements include:Assessing Tobacco Use: Percentage of the eligible population who were asked about their use of tobacco productsAssistance with Tobacco Cessation: Percentage of the eligible population who received the following components of this measure.Advising to Quit: Percentage of members 18 years of age and older who were current smokers, who were seen by a practitioner or qualified disease management representative during the measurement year and who received advice on tobacco use cessation Discussing Cessation Strategies: Percentage of members 18 years of age and older who were current tobacco users, for whom cessation methods or strategies were recommended or discussed (18)The American Academy of Family Physicians (AAFP) is also a leader in tobacco cessation clinical systems change initiatives. Its Office Champions Project, based on an Ask and Act program that encourages physicians to “ask” all patients about their tobacco use and “act” to support them in quitting, encourages system change within family physician offices to incorporate tobacco cessation services into daily practice. In pilot and demonstration projects, a variety of methods were employed, including electronic health records (EHR) that seamlessly integrate screening and treatment into the clinical workflow. AAFP is currently seeking 20 Federally Qualified Health Centers (FQHC) to implement the Office Champions model. It is critical to address this patient population because of the high rates of tobacco use and the higher incidence of second hand smoke exposure. (19)The myriad of supportive public health initiatives, implementation of tobacco use assessment and assistance performance measures and expansion of cessation coverage provide an unprecedented opportunity to expand the reach of cessation to an increased number of tobacco users. The integration of effective barrier free quitline referrals into practice workflows will be instrumental in accomplishing this objective. SECTION TWO: STANDARD DEFINITIONS FOR REFERRAL SYSTEMS A standard set of definitions is useful for fostering understanding within the quitline community, and for communicating objectives for referral systems with healthcare providers, state and federal governments, and the broader tobacco cessation community. We introduce terms to clarify the types of referral systems that are either currently in use or anticipated. See also the Glossary of Terms (Appendix A) for definitions of referral system components. Referral SourcesThe following describe the types of organizations and job positions that typically make quitline referrals.Provider ReferralA referral made by a licensed healthcare provider. A licensed healthcare provider is an institution (e.g., hospital, clinic, dental office) or an individual (e.g., physician, dentist, nurse practitioner) who provides patient care and is authorized to receive protected health information (PHI) under HIPAA as a “covered entitiy”. Providers are able to receive quitline feedback reports. Non-Provider ReferralA referral made by a community resource that is not licensed to provide patient care. A community resource can be an institution (e.g., public health department, community-based organization) or an individual (e.g., social worker, case worker) who works with tobacco users but is not authorized to receive PHI under HIPAA. Non-provider referrals are not eligible to receive quitline feedback reports. Referral TypesThe following provides definitions of the two main types of referrals. The main difference between the two is whether there is direct, written communication between the referral source and the quitline.Indirect ReferralAn indirect referral is that which is contemplated by the clinical protocol AskAdviseRefer. The tobacco user is advised of available tobacco cessation services, including quitlines and community based programs, by a healthcare provider, allied health professional or other community resource. The tobacco user is encouraged to contact a cessation program, and may be provided with phone numbers, information cards, brochures and other promotional materials. Indirect referrals include advice to contact 1-800-QUIT NOW or . The tobacco user is responsible for initiating contact with the cessation resource, and a quitline is not informed that a referral has been made. An indirect referral does not include any direct communication between a provider and the quitline, and does not generate any feedback reports on referral status and outcomes. Direct ReferralA direct referral occurs when a physician or other healthcare provider sends a written referral form to a quitline to refer a patient for quitline counseling, a process that is similar to referrals made to other healthcare professionals (e.g., specialists, therapists). A direct referral includes information necessary to contact the patient and to identify the provider and clinic making the referral. Direct referrals may also include other information such as patient consent to be contacted or medical consent to dispense NRT. In a direct referral, the quitline is responsible for contacting a referred patient, and for providing feedback reports to the referring physician. Direct referrals may be submitted by fax (“fax referral”) or electronically (“eReferral”). Referral MethodsThe following describe the different ways in which a direct referral is made.Fax ReferralFax referral is a type of direct referral in which information between a referral source and a quitline is sent or received via fax. Fax referrals can come from either provider or non-provider referrals. Fax referral systems may exchange two types of documents: referral forms and feedback reports. Fax documents can be paper, in which the file is sent or received using a fax machine, or electronic, in which the file is sent or received using electronic fax technology. Fax documents which are exchanged electronically are formatted as image files, such as PDF or JPEG. This means that they can be printed or read on the screen, but discrete data cannot be extracted from them. The information contained on fax referral forms must be entered manually into a quitline case management system. Providers that use an EHR may scan or file the report electronically into the patient’s file; otherwise they are likely to be printed and placed in the patient’s paper chart. Faxed documents are common among healthcare providers as they are deemed HIPAA-compliant for exchange of PHI.Electronic referral or eReferralElectronic referral, or eReferral, is a type of direct referral in which information between a referring provider and a quitline is sent or received electronically. eReferral systems are contemplated primarily for use with EHRs, which are used by healthcare providers. eReferral systems may exchange two types of documents: referral forms and feedback reports. eReferral documents are typically data files, such as CSV, XLS, or HTML. This means that, in addition to being read on the screen, discrete data can be extracted and used to auto-populate information in the quitline case management system. While it is technically possible for providers that use an EHR to extract data from feedback reports into an EHR, this isn’t in wide use today, as providers have many competing demands for EHR interfaces, and quitlines are low on the priority list.eReferrals can range from simple to complex. Examples of eReferral systems currently in use include:A text document is sent to a secure email address by the referring provider, and is then downloaded by the quitline. Information contained in the document is entered into the quitline case management system using either cut and paste or manual data reentry.An electronic referral form is created on a quitline website. Providers can complete the form online and submit it electronically to the quitline. Data contained on the form is then transferred automatically to autopopulate the case management system.eReferral forms from a large healthcare provider are aggregated in a batch file on an SFTP site, and then downloaded by the quitline. Discrete data is automatically extracted from the data file and used to auto-populate the quitline case management system. Bidirectional eReferralUsed occasionally to differentiate an eReferral system in which both referral forms and feedback reports are exchanged electronically between provider and quitline, from a system in which one document, typically the referral form, is sent electronically, while the other document, typically the feedback report, is sent by fax.Fully Integrated eReferralA fully integrated eReferrals system is the long term goal for the tobacco cessation community, and is consistent with the CDC’s vision for how quitlines should integrate with meaningful use of certified EHRs by healthcare providers. In a fully integrated eReferral system, the direct referral process with providers is fully automated and streamlined for maximum efficiency. See section on vision of an eReferral system [insert cross reference].Hybrid ModelsQuitlines will need to provide a variety of methods for sending and receiving PHI with providers and non-providers. A crawl (manual), walk (hybrid), run (fully electronic) system that allows providers and quitlines to gradually develop eReferral capabilities is recommended. Quitlines will need to maintain capabilities to receive referrals by phone, facsimile and eReferral, as healthcare providers will have differing levels of EHR use, and most non-provider referral sources do not use EHRs.The following graphic provides a summary of the hybrid capabilities that quitline service providers will need in order to meet the needs of all referral sources. PROVIDERHYPERSPACEQUITLINE1432560-4064000Initiate Referral1405890-4381500Transmit ReferralInterface with QuitlineCrawlPaper form filled outPaper forms sent by faxManual entry from paper form to quitline CMSWalkElectronic form downloaded; some fields prepopulatedeForms sent by fax, efax, email or secure internetManual entry from eForm to quitline CMSRunElectronic form in EHR, automatic completioneForms sent by secure exchange, daily or real timeAuto-populate from eForm to quitline CMS1424305-5143500Interface with EHR1456055-5334000Transmit ReportCreate ReportCrawlPaper feedback report scanned into EHRPaper feedback report sent by faxPaper feedback report created and printedWalkeReport autosaved to patient medical recordeReport sent by fax, efax, email or secure interneteReport created; some fields prepopulatedRuneReport autosaved to patient medical record, data?fields autopopulated eReport sent by secure internet, daily or real timeeReport created, completed automatically in quitline CMSSECTION THREE: MAJOR COMPONENTS OF REFERRAL SYSTEMS Goals and Desired Outcomes When quitline callers are asked during intake how they heard about a quitline, the top referral sources cited include the following: TV advertising campaigns underwritten by federal (CDC) and state government initiatives, indirect referrals from physicians and other healthcare professionals, and friends and family. There is currently no standard reporting system for quitline referral sources, but a review of quitline client data suggests that, while the order of magnitude varies from quitline to quitline, these are the three most common. [insert endnote] Less than a quarter of quitline participants are referred by healthcare providers using a direct referral. These referrals are received by facsimile and then manually entered into quitline case management systems. Once a referral is received, the quitlines acknowledges receipt and provides feedback to referring providers at several points during the cessation process.There is a significant opportunity to increase the number of patients receiving cost-effective tobacco cessation counseling by increasing the number of referrals to quitlines from healthcare providers. Most quitlines are equipped not only to provide smoking cessation services directly, but also to triage callers to the appropriate cessation resource based on eligibility criteria, insurance coverage, geography, and caller demographics. Currently, the main impediments to quitline referrals are 1) lack of provider knowledge about quitline resources available, 2) lack of an easy referral workflow for providers, and 3) lack of incentives for providers to make referrals for smoking cessation. Quitline capacity to accommodate increased numbers of enrollees and limited funding for service provision are also significant barriers.The goals for improving referrals to quitlines by providers and other community resources are to:Ensure that tobacco users access cessation services, by encouraging the use of either contact or indirect referrals to a quitline. Provide forms, tools and processes that make it easy for providers to include tobacco cessation interventions in their practice workflows.Create feedback mechanisms and reports to assist quitlines and healthcare providers to target outreach and in-service activities to specific hospitals and healthcare providers.Work with local healthcare systems to integrate quitline referrals with broader initiatives to build local and regional health information exchanges. Conduct outreach activities and detailing to promote use of quitline referrals. Broaden referral sources to include non-healthcare providers, such as community centers, nonprofit charities, low-income housing, and other community resources. The use of both contact and indirect referrals should be encouraged in outreach activities and academic detailing. Each method is beneficial in driving referrals to quitlines, and offers different pros and cons.ProsConsIndirect referralRelatively easy to implement; requires least amount of provider timeHigh acceptability; proven to drive large numbers of callsAligned with the evidence base for telephone counseling (i.e., quitlines are effective for those who call)May have a broader public health impactMeets clinical quality measures for tobacco cessation interventionLower certainty that patient will follow through with recommendation to call quitlineNo feedback to providers on patient engagement, NRT status or outcomesNo ability to track and report on referrals by hospital, clinic or individual providerDirect referralEliminates need for patient to initiate quitline callGreater certainty that patients will receive treatmentProvides feedback to providers on patient engagement, NRT status and outcomeMeets clinical quality measures for tobacco cessation interventionFeed data back directly into an EHR; easier to track physician compliance.More aligned with the goal of systems change to support cessation interventionsRequires more effort to setup provider workflowMay require more oversight to sustain referrals Greater expense and effort for quitlines to contact referred patientsLess than half of referred patients enrollPotential benefits to healthcare providers of adopting a fully integrated referral system include:incorporates quitline referrals into existing workflow and EHR recordsimproves referral consistency and time efficiency while minimizing processing errorsincreases options and tracking for providers to meet meaningful use objectives and clinical quality measures and qualify for incentive paymentsprovides documentation for billing Medicare and other providers for cessation counseling servicesfacilitates comprehensive health recording and continuity of care with feedback to providers and patients’ records extends the scope and quality of care for one of the preventable forms of health risk behaviorsfacilitates measurement of performance and health impact at both the patient and population levelQuitline referrals provide a unique opportunity to extend providers’ capacity and make evidence-based effective care available to essentially all U.S. and Canadian citizens.Referral Process FlowchartThe high level workflow described in this paper is used by providers and quitlines to generate referrals, initiate contact with patients, and report back on patient disposition, regardless of whether the referral is received by telephone, facsimile or electronic exchange. This is important, as quitlines must be equipped to handle a variety of referral types, depending on the technological capabilities and preferences of each referral source. The major difference from a workflow perspective between telephone or fax referrals and eReferrals is that an electronic referral system cuts down on illegible handwriting and manual data entry, thus increasing productivity for both providers and quitlines.The process flowchart illustration describes the overall workflow:Referral Process – Provider WorkflowWorkflow OverviewThis section describes the workflow activities specific to making a direct referral to a quitline. This workflow is also consistent with clinical quality measures for tobacco use assessment and tobacco cessation including those developed for meaningful use, Joint Commission, and other quality improvement initiatives. Referring Patients to a QuitlineA typical workflow used to make direct referrals consists of the following major activities [insert cross reference to flowchart]:Tobacco use status should be treated as a vital sign, and documented for every patient at every visit. Current tobacco users should receive a cessation intervention, in which the provider asks if the tobacco user is willing to quit in the next 30 days. If the patient is willing, the provider can make either a contact or indirect referral to appropriate cessation resources.In an indirect referral, the provider suggests cessation resources that are available to the patient, and provides contact information. Information sheets, brochures, magnet cards and other promotional materials may be provided to the patient, and no further action is required by the provider. In an indirect referral, the patient is expected to initiate contact.In a direct referral, the provider initiates a written referral to a quitline. The provider asks the patient for consent to be contacted by and receive feedback reports from a quitline, and discusses pharmacotherapy options. If the patient agrees, the provider completes the referral form, provides medical consent and any prescriptions for pharmacotherapy, and submits the referral form to the quitline. Once a patient is referred, referring providers typically receive feedback reports from quitlines at various milestones {insert cross reference]. These reports should be reviewed by the provider and results documented in the patient’s medical record. Referral FormsReferral forms should contain the following data categories:Patient demographic informationPatient contact informationBest time and day to callProvider/clinic contact informationNRT authorizationThe NAQC eReferral workgroup will establish a national standard for referral forms. It is strongly encouraged that standard formats and data elements be adopted by the quitline community in order to facilitate integration with national standards and electronic exchange of protected health information. Medical Consent for PharmacotherapyMost quitlines offer some type of pharmacotherapy program in accordance with U.S. Public Health Service recommendations to combine multiple sessions of counseling with pharmacotherapy for the most effective means of achieving tobacco cessation. (6) Over 80% of U.S. state quitlines offer pharmacotherapy, with free NRT being the most common. The following table shows the distribution of available cessation medications by U.S. state quitlines. Medications are not available through the Canadian quitlines. Most private quitlines offer pharmacotherapy benefits through their health plan or other third party payer. Prescription Pharmacotherapy: Several public quitlines and many private quitlines offer prescription cessation medications. These programs typically require a prescription from the referring provider, a co-pay from the participant, and confirmation of enrollment in a quitline coaching program. Quitlines will often work with a pharmacy partner who is responsible for receiving and shipping prescription medications. Participants are typically responsible for obtaining and submitting the required prescription from their provider.NRT Consent: Quitline coaches are trained in the use of common pharmacotherapy products, including precautions and contraindications, side effects, dosage and duration. (6) Medical screening is typically included in accordance with NRT labeling requirements. NRT is typically supplied to participants meeting the following requirements: 2780665121920At least 18 years of ageObtains medical consent form if any of the following conditions are present (per NRT warning label): pregnant, breast-feeding, heart disease, recent heart attack or stroke, irregular heartbeat, high blood pressure not controlled by medication Most quitline service vendors will assumes full responsibility for screening candidates, receiving medical authorization from participants’ physicians as necessary, ordering NRT and having it shipped to the participant’s home.Medical consent can serve as a deterrent to participants completing the recommended number of counseling calls, which affects quit rates. A review of the impact of medical consent form (MCFs) on enrollment and participation rates was conducted by one quitline, which found that 9% of participants did not return their MCFs, and therefore were not eligible for NRT. Participants who returned their MCF and received NRT completed 3.29 coaching calls on average, whereas those who did not return their MCF completed an average of 1.55 coaching calls.Direct referral forms should include an optional statement of medical consent for NRT therapy to streamline the enrollment process and eliminate a potential barrier to participation, such as:?I authorize the Quitline to send over-the-counter nicotine replacement therapy to this patient.Patient ConsentCurrent fax referral forms often include an acknowledgement by the patient that he or she is ready to quit tobacco and that the provider will be informed of results. While this has been a common practice, it is seen as a barrier to referrals by practicing physicians and is not recommended for referral forms. Since referral forms typically ask patients to provide a phone number and best time and day for a referral, patient consent is implied. In addition, several quitlines report using an opt-out function for direct referrals. There may also be confusion about what is being consented (contact or counseling), and if not checked, could lead to referrals being considered invalid. Finally, providers make all sorts of referrals (e.g., specialty consults, physical therapy) without a requirement for patient consent, and singling out quitlines seems odd.Where patient consent is used, sample acknowledgments include:I am ready to quit tobacco and request that the quitline contact me to help with my quit plans.I understand that the quitline will inform my provider about my participation and quit results. Patient agreed with provider to be referred to the quitline and to report results.Consent can be indicated by any of the following methods: signature, initials, checkbox. Referral Process – Quitline WorkflowWorkflow OverviewThe primary responsibilities of a quitline are to attempt to engage referred individuals and enroll them in quitline services, to make reasonable attempts to contact patients referred by fax or eReferral, and to provide feedback to the referring provider on the disposition of the referred patient [insert cross reference to flowchart]. Processing Referrals at the QuitlineThe overall workflow used by quitlines to process direct referrals consists of the following major activities [insert cross reference to flowchart]:Referrals are received at the quitline, either individually or in batch, either by facisimile or electronic file. To comply with HIPAA security measures, the fax machine, electronic fax or electronic file must not be accessible by anyone who is not an authorized user of PHI. All referral form information is entered into the quitline case management system, typically within 24 hours of receipt. In an eReferral system with a working interface, information from the referral form may trigger creation of a new participant record and autopopulate the record with information contained in the form.The case management system automatically queues an outbound call to the participant at the preferred time indicated on the referral form. Scheduled calls are distributed to quitline intake staff for completion of calls. Predictive dialers are useful for streamlining this process and improving call center productivity, as up to 75% of outbound calls to participants typically reach voice mail, a busy signal, or no answer. The first call attempt is typically made within 48 hours of receipt.When a referred individual is reached by telephone, the quitline intake staff explains the quitline program and determines whether he or she wants to participate in the program or not. If yes, eligibility and intake forms are completed and the participant is enrolled. If no, record is made that participation was declined and the file is closed. A feedback report is sent to the referring provider that documents whether their patient accepted or declined cessation services.If a referred individual is not reached on the first attempt, quitline intake staff will use a reset process to make additional calls on separate days. If a referred individual is not reached within 3 to 5 calls, the profile is marked as unreachable and the file becomes inactive. A letter or email may be sent to the individual notifying them that call attempts were unsuccessful and inviting them to call the quitline. Once a patient is enrolled, quitlines typically provide feedback reports to referring providers at various milestones. [insert cross reference]Feedback Report ContentsFeedback reports should contain the following data categories:Patient identifying informationEnrollment status (e.g., accepted, declined)Program status (e.g., active, ineligible, disengaged)Disposition (e.g., web only, multi-call) NRT status and dosingOutcomes (if available)Quitline service providers will need policies and procedures in place to ensure that feedback reports are provided only to covered entities and business associates that are authorized users of PHI. The NAQC eReferral workgroup will develop a national standard for feedback reports. It is strongly encouraged that standard report formats and data elements be adopted by the quitline community in order to facilitate integration with national standards and electronic exchange of protected health information. Providing Feedback to Referring ProvidersFeedback reports are routinely provided for direct referrals in the U.S. (85%), but not in Canada (30%). Canadian quitlines are far more likely to report back a patient’s quit status than in the U.S. (30% vs. 12%), but both countries are lacking in comparison to providers’ stated desire for outcomes information. Quitlines typically acknowledge receipt of and provide feedback to referring providers at several points during the cessation process. While the number of feedback reports varies by quitline, common report timing includes: When a fax referral is received or is invalidAt the time a patient enrolls in coachingIf a patient is unreachable or declines enrollmentWhen medications are ordered for a participantWhen a patient completes the programWhen a patient disenrolls for any reasonIf patient quit status at 7 months is availableWhen providers were asked what information they would find beneficial to receive on referred patients, they reported wanting enrollment status, program status, disposition, and details on all NRT provided. They would also like to receive outcomes of the intervention as measured by quit status. This presents problems for current workflows, as many state quitlines use an outside survey vendor to collect outcomes data, and such data is not fed back into the quitline case management system, and thus not reportable to referring providers. Further, quit outcomes are typically collected on a statistically significant sample size, and not the entire population. Quitlines will need to develop new ways to report on counseling outcomes in order to provide more useful information to providers. One area worth exploration is the use of online surveys to supplement the more detailed phone surveys used to measure quit rates. Feedback reports are typically included in a patient’s medical record, either added to a patient chart or scanned into an EHR patient record. In most clinic and hospital settings today, feedback reports are not tightly integrated into EHR systems, as no discrete data is imported from the reports back to the EHR. An opportunity exists to more tightly couple quitline feedback into the EHR, such that medications provided by the quitline could be added to the patient’s chart, and referrals could be logged as meeting provider quality measures to provide a cessation intervention. Feedback reports may be sent by any of the secure transmission methods: fax machine, electronic facsimile, or electronic file transfer. As quitlines move towards bi-directional eReferral systems, it is important that these feedback reports fit into providers’ existing workflow for how results letters are received, uploaded and displayed in EHRs.Providing Feedback to Quitline ClientsAggregate reports are useful for determining quitlines’ reach into the healthcare community within a given geographic area. These reports can help target outreach efforts that should be made to individual hospitals or clinics, and to identify opportunities to pursue public/private partnerships, such as where a large number of referred patients are determined to be ineligible for state quitline services. Aggregate reports prepared for quitline clients may include:Summary Report – by Institutional Provider: number of referrals received by hospital/clinic for current month and year to date, with disposition of referrals (e.g., accepted service, declined services, ineligible, unreachable). Useful for determining success of outreach efforts to area providers and for identifying opportunities for public/private partnerships.Summary Report – by Individual Provider: number of referrals received by individual clinician for current month and year to date, with disposition of referrals (e.g., accepted service, declined services, unreachable). Useful for tracking effectiveness of in-service efforts to individual providers and for assessing performance against quality improvement measures for tobacco cessation.Detailed Report: referral status by patient, including provider name and clinic, patient name and demographics, and insurance information. Useful for determining status by individual patient, available to authorized users of PHI. Preparing for an Electronic Referral SystemOverviewNAQC has formed a workgroup for electronic referrals to achieve the following goals: 1) all state quitlines are prepared to implement eReferrals with health care providers no later than 2015; 2) NAQC works within the healthcare system; and 3) EHR vendors are informed about NAQC activities. To accomplish this goal, the workgroup will develop referral systems schematics, standards, and resource materials for use by quitline funders and quitline service vendors, and will suggest the type of technical assistance and support needed to coordinate implementation with meaningful use and HIE initiatives nationally and locally. A report will be produced for NAQC members that provides guidance, suggested resources and timelines. The report will serve as a compliment to this paper, focusing on the technical issues required to automate the referral processes outlined herein. eReferral VisionThe goal of a fully integrated eReferral system is to build an electronic system that enables healthcare providers to submit feedback reports electronically using a HIPAA-compliant health information exchange. Ideally, providers using an EHR will be able to generate a referral form for tobacco cessation automatically from their EHR, and receive back feedback reports which are automatically routed to their inbox and/or filed in their EHR. The eReferral system will be designed to comply with national standards for EHRs certified for meaningful use, and will be compatible among states and quitline vendors, to facilitate formation of a national clearinghouse for quitline referrals, and to avoid the time and expense of having each quitline “reinventing the wheel”. The ability to send and receive forms by fax or secure email will need to be provided as an option for providers that lack the required components for a fully automated system. Process Flow for a Fully Integrated SystemProviders will access an eReferral form through their EHR, ideally with the equivalent of an “easy button” that, with a single click, can generate a patient referral to a quitline. Ideally, access to this form will be coupled with the EHR vital sign data on tobacco use, to simplify the process for provider offices. The EHR will populate patient demographic data, physician information and other instructions on the eReferral form, which will be submitted by the EHR via a secure exchange and routed directly to the state quitline. (Quitlines will be enrolled as a provider on the appropriate secure network or HIE.) The quitline service provider will build an interface to receive the eReferrals on behalf of the state quitline. The interface will capture all eReferral information and use it to populate the quitline case management system. Quitline customer service representatives will then contact the patient to initiate enrollment. Once patient contact has occurred, the quitline case management system will generate an automatic feedback report that informs the referring provider of the intervention with the patient, including any NRT ordered through the quitline. The feedback report will be sent back through a secure exchange to the referring provider, where a standard interface will download it into the provider’s EHR. Data contained within the feedback report will automatically populate the EHR with results information. Components of an eReferral System5715-53340The components of an eReferral system include:Standard documents for referral forms and feedback letters. The document format should be consistent with EHR requirements for meaningful use (e.g., HL7 CDA), and should include standards for required and optional data fields, document format and document transport. A secure exchange for sending and receiving protected health information (PHI), compliant with HIPAA security and privacy provisions, and for enduring that only authorized users have access to PHI. Several options are available, including secure email, secure file transfer protocol (SFTP) sites, public or private health information exchanges, and the National Health Information Network (NHIN).Interface engine to send and receive data, customized for the specific requirements of each EHR and quitline case management system. Basic interfaces allow documents to be sent and received between two technology platforms, and stored as a file, typically in TXT, PDF or JPEG format. Advanced interfaces allow discrete data (e.g., patient demographics, smoking status) to be uploaded, transmitted and downloaded from one database to the corresponding data field in another database. Preparing for eReferralThe good news for quitline clients is that much of the work required to build an eReferral system falls to the entity responsible for operating the quitline case management system, often a quitline service vendor. Currently, there are 15 organizations that operate all 53 state quitlines. (20) Four organizations, accounting for 43 state quitlines (80%), have begun implementing pilot eReferral programs between state quitlines and selected provider EHRs, and one state-run quitline has also implemented an eReferral system.Once a quitline service vendor builds out eReferral capability, it can be used by multiple quitline clients, minimizing costs for implementation and ongoing maintenance. The quitline service vendor is responsible for implementing the following eReferral components:Standard documentsInterface engineUser authenticationSecure file exchangePublic quitlines can assist their quitline service vendor by helping to identify what health information exchanges and types of EHRs are being used by large provider groups in their region. Examples of activities that state quitlines can undertake to help facilitate eReferral implementation include:Comply with national standards being developed for a common quitline referral form and feedback letters.Identify key constituents within the state health department to learn about existing initiatives and expertise in electronic health information exchange.Interview key stakeholders in the state to learn about regional health information exchanges (HIE) that may be in development.Determine which HIE and EHR vendors have a large user base in your state. Find out if provider directories are maintained and updated, as these are useful for routing electronic files. Create a priority list of healthcare systems for planning implementations. Identify a pilot site if needed. Discuss eReferral goals for with your quitline service vendor.Provide academic detailing, initial healthcare system/provider training and ongoing assistance, until systems integration is complete SECTION FOUR: CREATING SYSTEMS CHANGEOverviewBoth the quitline community and providers are responsible for ensuring that tobacco interventions become an integrated component of healthcare delivery. (6) In a 2007 Institute of Medicine report, systems integration was listed as the “single most critical missing ingredient needed to maximize the yet unrealized potential to significantly increase population cessation rates.” (21) Tobacco use treatment needs to be mainstreamed into practice flow practices so that providers can better help individual users quit, either directly or by referring them to resources such as quitlines. (22) This is critical for all quitlines, whether publicly or privately funded or funded in partnership. It is also important to remember that, although health care reform focuses on traditional medical clinicians, invested practitioners include many other types of providers, e.g. dental and behavioral health, as well as community health workers eager to improve the health of their clients. Time a Key Barrier2444750950595Adherence to Clinical GuidelinesThe 5 A's Guideline (6), while representing an ideal approach to the clinical treatment of tobacco dependence, is seldom fully implemented by physicians, primarily due to time constraints and limited reimbursement and resources. It is important that referral systems be created that are quick and easy to implement.Quitlines as Triage ResourceLack of time and resources is frequently mentioned by physicians as a reason why tobacco cessation counseling is not routinely provided to patients. Quitlines need to emphasize to providers that they can serve as a valuable triage resource. Most quitlines are equipped to triage referred patients to the appropriate cessation resource, including private quitlines and community-based services, based on eligibility criteria, insurance coverage, geography and caller demographics. Quitline coaches are trained to assist callers in selecting the appropriate type and dosage of NRT, and can help process orders for pharmacotherapy. Physicians benefit by ensuring that clinical guidelines are followed, but without adding an additional burden to their clinical workflow. Quitlines routinely provide results information back to referring providers, ensuring that the feedback loop is complete.PartnershipsHealthcare ProvidersOutreach activities can be very time and resource intensive for quitline funders. Lessons learned from state quitlines that have initiated outreach or detailing programs inform us that it is best to start by prioritizing referring partners in the state. Examples of good candidates include:Hospital systems that include multiple hospitals and clinics in a geographic area. These systems may have centralized staff with responsibility for implementing tobacco cessation best practices in their facilities.Hospital systems, physician associations or health plans that have or are forming an Accountable Care Organization (ACO). ACOs have entered into agreements with CMS, taking responsibility for the quality of care furnished to people with Medicare in return for the opportunity to share in savings realized through improved care. Since smoking is the second largest driver of preventable health care costs (exceeded only by obesity), ACOs have financial incentives to help their patients quit smoking. A list of ACOs that are participating in the Medicare Shared Savings program is available at health providers. Current smoking among U.S. adults with mental illness is 70% higher than smoking among adults with no mental illness. About 36% of adults with mental illness are smokers, compared with 21% of adults who do not have a mental illness. Nearly 1 in 5 adults in the U.S.—about 45.7 million Americans—have some form of mental illness. (24) Providers of care for members of priority communities. It is critical to reach persons in priority communities that suffer from tobacco related disparities (e.g. CDC’s six funded priority community networks), including the low socio-economic demographic. In 2010, in the U.S., 25.7% of adults below the poverty level smoked compared to 16.4% at or above the poverty level. (1) The 2010 NHIS found that Hispanic smokers were less likely (34.7%) to have received advice to quit than other racial/ethnic populations and only 35.3% of those without health plan received cessation advice. (3)Healthcare providers are inundated with suggestions for improving care, and can only tackle so many system changes at a time. It is helpful to tie outreach activities to existing improvement objectives that providers may be addressing, such as complying with meaningful use or Joint Commission clinical quality measures.Additional resources for engaging healthcare providers and building public-private partnerships is available from NAQC at and emerging referral models.Health Plans and EmployersSome state quitlines have proactive partnership programs, under which health plans and employers in their state offer tobacco cessation benefits under the umbrella of the state program. Such partnerships are beneficial to state quitline funders, as they preserve state funding to be used for priority populations, such as the uninsured and underinsured. Quitline callers benefit, as they aren’t transferred or referred to a different cessation program, which creates barriers to use. Health plans and employers benefit, as their constituents receive evidence-based services from quitlines with publically reported quit rates. And quitline service providers benefit, as they can provide services regardless of payer type.Soliciting partnerships with health plans and employers is often done collaboratively between a state quitline and its quitline service vendor. Many quitline service vendors offer cessation services to private entities, and will have proposals, marketing materials and other resources useful for approaching a potential partner. From an operations standpoint, quitline service vendors should have the capability to provide separate agreements, invoicing and reporting to each state partner. Non-Provider Referral Sources Although most published reports have focused on physician or allied health providers within a traditional healthcare setting- clinic or hospital, Massachusetts has successfully incorporated community health centers and providers in other categories, such as nursing homes, public housing programs, visiting nurses, or other human service providers in their referral program. (12) The Bronx Breathes project found enthusiastic participation by unexpected clinical partners, thought to be due to the presence of a tobacco champion. A dental clinic; a Women, Infants and Children (WIC) center; and a nonprofit community-based organization that trains peer educators have made significant numbers of referrals. (23) Including nontraditional referral sources has also presented its challenges. Over the years, University of Wisconsin-Center For Tobacco Research And Intervention (UW-CTRI) has set-up and provided training and technical assistance for fax referral at employers/businesses, community organizations, dental practices, mental health agencies, and substance abuse agencies.?The most sustainable programs in addition to traditional healthcare facilities were dental practices, and mental health and substance abuse agencies.?Those that were not sustainable were further removed from clinical care.?Even in larger companies that had a nursing staff or?a wellness?program, challenges were encountered. There often was no one responsible for assessing health and helping people improve their health or to quit. Another factor?in?non-healthcare businesses/employers, was employee hesitation of discussing their smoking with their employer (vs. their health provider), and getting outcome data. (24)It is important to expand the pool of eligible referrers as feasibly possible with available resources to maximize reach, especially among those who primarily serve those with limited access to traditional healthcare. Even though, in some cases, eReferrals may not be possible, extra training and technical assistance may be required, and HIPAA regulations may prohibit feedback, the value of connecting all tobacco users to cessation services cannot be overemphasized.2012 Quitline Profiles reveal that over 80% of U.S. and Canadian quitlines allow clinicians or non-clinicians in a healthcare setting to refer patients either through Fax or electronic programs, while a slightly lower percentage in the U.S. (70%) allowed providers in a community-based organization to refer. (4) It is important to expand the pool of referral sources as feasible with available resources to maximize reach, especially those with limited access to traditional healthcare, including the underserved and priority communities. While for some of these sources eReferrals may not be possible, extra training and technical assistance may be required, and HIPAA regulations may prohibit feedback, the value of connecting tobacco users to cessation services cannot be overemphasized. The use of non-provider referrals should also be emphasized, and promotional materials made available.Other PartnersAs systems are developed and implemented, it is essential to include all stakeholders in the referral process. The development of fully integrated eReferral systems will require close integration with local and regional efforts to build health information exchanges. Hospital systems, physician associations, EHR and HIE vendors will need to be part of the systems development process.PromotionsTypes of Promotions OfferedPromotions for implementing, sustaining and advancing provider referrals have varied among quitlines, ranging from provider starter kits to customized forms, email, newsletter, and fax correspondence. These have all been shown to be successful to various extents. Wisconsin successfully used champions at referral sites to promote and support provider referrals and strengthen partnerships with clinic systems. In 2012, 60% of U.S. and 67% of Canadian quitlines provided customized referral/consent forms with 55% and 42%, respectively, providing customized provider feedback reports. A slightly lower percentage provided staff training, 53% and 58% respectively. Over 80% of quitlines provided quitline and/or referral brochures while few provided quitline/referral newsletters. (NAQC)Detailing, Technical Assistance and Training“If you build it, they will come” may hold true for baseball, but not provider referral systems. Outreach on a practice by practice basis is required to build effective and sustainable referral patterns among providers. Lessons learned from public and private quitlines include the following components of a successful outreach program:Getting in the door: primary care practices are inundated with prevention initiatives that they should undertake, and visit time is very limited. One approach that has worked is to leverage the meaningful use core measure for tobacco screening and intervention as a motivation to change practice workflow.Finding a champion: establishing a successful referral process requires practices to change existing workflow. Redesign is most likely to occur if someone within the practice, typically an office manager or medical assistant, steps up as the project owner.Leveraging staff: it is not realistic to expect physicians to add tobacco screening and counseling to their already compressed visit time. Instead, train medical assistants or nurses to assist in the process. One approach is to have the medical assistant or nurse screen for tobacco use as part of their process of obtaining vital signs. If positive for tobacco use, the assistant can use motivational interviewing to determine whether the patient is receptive to cessation information, and fill out the referral form in advance of the physician’s visit with the patient.Engaging the healthcare provider (physician/physician assistant/ nurse practitioner): emphasize that less than a minute’s time is required to complete a brief intervention. Rely on medical assistants or nurses to initiate the referral and provide information, leaving the care provider’s time free for critical positive reinforcement and discussion of pharmacotherapy options, including prescription NRT, bupropion and varenicline. Reinforce with care providers that the quitline is a resource that can triage patients to the right cessation resource, assist patients to select NRT, and initiate evidence-based counseling. Eliminating barriers: while provider training on referral processes is desirable, it should be easily accessible and succinct. eLearn opportunities, such as webinars, will minimize barriers. Make sure that quitline forms and brochures are readily available in exam rooms, and that the office champion makes sure supplies are restocked. Use referral forms that are easy to complete, such as allowing providers to affix preprinted patient labels to a referral form rather than handwriting the information. Find out if a provider’s EHR produces a generic referral form that can be easily tailored for quitline purposes. Offering assistance: provide the option for providers to receive brief training on tobacco cessation counseling, such as motivational interviewing techniques, updates on pharmacotherapy, and overview of available resources. Offer webinar training and provide CME credit to encourage attendance.Financial Implications of Referral SystemsWho pays for referred patients? How do referring providers get paid? This section reviews financial implications associated with building referral systems for both providers and non-providers.Quitline FundingMost calls to state quitlines are funded by government sources, with only 10% of quitlines reporting that they receive third party payments from health plans. For U.S. quitlines, the highest proportion of funds come from MSA, general funds, state tobacco taxes, and non-MSA tobacco settlement funds, while the majority of Canadian quitlines report receiving funds from provincial general funds and Health Canada. (4) While most referral systems generate caller volume that is incremental and not transformational, care should be taken to insure that projected increases in quitline volume are covered by funding budgets. In-service and detailing programs should inform providers of how quitline services are paid for, and reinforce the role of quitlines as triage resources. For example, some states will pay for a quitline enrollment for any state resident, regardless of whether they have health insurance. In other states, quitline eligibility is limited to callers who do not have private coverage, such as the uninsured, Medicare or Medicaid beneficiaries. Provider ReimbursementProviders can bill Medicare or Medicaid for tobacco cessation counseling. Most private health plans do not offer coverage at this time. Medicare covers two levels of tobacco cessation counseling (intermediate and intensive) for beneficiaries who use tobacco and have been diagnosed with a recognized tobacco-related disease or who exhibit symptoms consistent with tobacco-related disease. Counseling sessions may be performed “incident to” the services of a qualified practitioner, and refer to face-to-face patient contact at one of two levels:Intermediate (greater than 3 minutes and less than 10 minutes); orIntensive (greater than 10 minutes)Cessation counseling of 3 minutes or less in duration is “minimum counseling” and is included as part of each routine evaluation and management (E&M) visit and not separately billable. A tobacco cessation counseling attempt occurs when a qualified physician or other Medicare-recognized practitioner determines that a beneficiary meets the eligibility requirements and initiates treatment with a cessation counseling attempt. Medicare covers two cessation attempts per year:Up to four cessation counseling sessions per attemptTwo cessation counseling attempts (or up to 8 cessation counseling sessions) in a 12 month periodAfter 11 months have passed since a first counseling session, an additional eight counseling sessions during a second or subsequent year after 11 months have passed since the first Medicare-covered cessation counseling sessionsCoverage is divided into programs for symptomatic and asymptomatic Medicare beneficiaries. Symptomatic: Outpatient and hospitalized beneficiaries who 1) use tobacco and have been diagnosed with a recognized tobacco-related disease or 2) who exhibit symptoms consistent with tobacco-related disease. Asymptomatic: Beneficiaries who use tobacco (regardless of whether they have signs or symptoms of tobacco-related disease, and 1) are competent and alert at the time that counseling services are provided; and 2) where counseling is furnished by a qualified physician or other Medicare-recognized practitioner.Following is a summary of diagnosis codes and procedure codes that are used to bill Medicare for tobacco cessation counseling.SYMPTOMATIC PATIENT(presenting health issue is a tobacco-related disease)ASYMPTOMATIC PATIENT: (tobacco user presenting with any health issue)CPT Billing CodeCPT Billing Code - 99406: $13.11Intermediate: 3-10 minutes Tobacco Cessation Intervention CounselingCPT Billing Code - 99407: $25.55Intensive: >10 minutes Tobacco Cessation Intervention CounselingBill appropriate E&M visit with modifier 25 attachedBilling Code G0436: $13.42Intermediate: 3-10 minutes Tobacco Cessation Intervention CounselingBilling Code G0437: $27.12Intensive: >10 minutes Tobacco Cessation Intervention CounselingCan also bill an E&M visitDiagnosis codeReport 305.1 - Tobacco-use disorder AND related condition of interference with medication. (Example: 493.9 Asthma)305.1- Tobacco use disorderCoinsurance/DeductibleNot waivedWaived - patient has no out of pocket expenses\SECTION FIVE: A REVIEW OF THE EVIDENCEThe preponderance of published studies center on fax referral programs in clinical settings. Although many process and outcome results have not been published, notable?findings from a literature review will be highlighted. The discussion will also focus on the few results available, generally from pilot projects, on systems integration of tobacco use assessment and?cessation assistance?into electronic health records and pilot e-referral implementation. The evidence section will end with a review of the state and provincial referral data from the?NAQC 2011 Survey of?Quitlines and 2012?Quitline Profiles. In April 2002, Massachusetts established QuitWorks, the first referral program linking healthcare organizations, providers, and patients to the state's tobacco cessation quitline. With limited funding to promote the quitline directly to consumers through a media campaign, QuitWorks’ provider referrals have become the primary source of quitline clients. An analysis of QuitWorks’ data showed 3 phases in referrals between April 2002 and March 2011. (Table) During the first phase, from April 2002 through November 2005, monthly referrals increased from approximately 100 to 325, an annual percentage change (APC) of 38.3%. During the second phase, from December 2005 through January 2009, the number of referrals to QuitWorks did not change significantly. During the most recent phase, the average number of monthly referrals per institution increased by 117%, from 14.4 to 31.2, accounting for about 80% of total quitline client volume. At the same time, the proportion of total referrals from the top 10 referring institutions decreased from 54% to 37%, indicating that many new providers were trying QuitWorks even as the top referrers were increasing their average number of monthly referrals. Influential factors included partnerships with stakeholders, periodic program promotions, hospital activities in response to Joint Commission tobacco use measures, service evolutions, provision of nicotine replacement therapy for referred patients and electronic referral options.PhasesAnnual Percentage Change (APC) Monthly ReferralsInfluencersApril 2002 – November 2005 (APC = 38.3%, P < .001).promotion effort in 2002 and 2003, including delivery of QuitWorks’ kits door-to-door2005 - hospital activity to meet Joint Commission tobacco measures[expanded promotions to hospitals and community health centersDecember 2005 -January 2009(APC = ?7.6%, P = .30).on-site technical assistance and clinical training servicesFebruary 2009 – March 2011(APC = 69.2%, P < .001)repetitive low-cost promotions announcing free nicotine patchesperiodic free e-mail, newsletter, and faxpromotions, conducted each year by MDPH and health plan partners, also increased in 2009 and 2010fully electronic referralsIn 2010, Massachusetts launched a fully electronic version of QuitWorks in partnership with the entire Atrius Health/HVMA 21-clinic system, using an interface program that accepts referrals from any electronic health record with patient medical record identification. The interface program also has the capability to transmit feedback reports electronically to the referring provider organization. (12) Quitline referrals doubled in six matched months between 2009 and 2010 after e-Referral launch. (26) Multi-State Collaborative Webinar May 2012QuitWorks' history demonstrates that tobacco cessation referral programs can reach substantial numbers of tobacco users; benefit providers and healthcare organizations; and contribute to sustainable systems-level changes. Since inception, QuitWorks has primarily received referrals from 4 types of facilities — hospitals (56.0%), outpatient clinics (14.0%), community health centers (10.1%), and provider practices (8.7%). The remaining 11.3% consists of providers in other categories, such as nursing homes, public housing programs, visiting nurses, or other human service providers. All referring providers receive two reports on each referred patient who provides consent— one within 5 weeks on quitline attempts to reach the patient and the services accepted, and a second quit status report 7 months later. (12) The sustained engagement of all major commercial and Medicaid health plans with QuitWorks and their endorsement and promotion of the program have been invaluable in reaching thousands of providers each year. In addition, QuitWorks’ promotions (chiefly inexpensive messaging delivered through partners) have contributed both to an expanding referring provider base and increasing integration into healthcare delivery. Massachusetts has also been at the forefront of examining the impact of system-wide brief interventions with smokers on smoking prevalence and healthcare utilization. Review of primary care office visits of 104,639 patients at 17 Harvard Vanguard Medical Associates (HVMA) sites showed that twelve met the operational definition of ‘‘systems change’’, achieved the first month that more than half of all office visits at a given site included an identification for smoking. In addition, in all following months, the rate of cigarette smoker identifications could never drop below 50% and there had to be at least 12 consecutive months with rates above 50%. Decreases in self-reported smoking prevalence were 40% greater at sites that achieved systems change (13.6% vs. 9.7%, p<01). On average, the likelihood of quitting increased by 2.6% (p<0.05, 95% CI 0.1%–4.6%) per occurrence of brief intervention. For patients with a recent history of current smoking whose home site experienced systems change, the likelihood of an office visit for smoking-related diagnoses decreased by 4.3% on an annualized basis after systems change occurred (p<0.05, 95% CI 0.5%–8.1%). There was no change in the likelihood of an office visit for smoking-related diagnoses among non-smokers. These data suggest that a systems approach can lead to significant reductions in smoking prevalence and the rate of office visits for smoking-related diseases. Most comprehensive tobacco intervention strategies focus on the provider or the tobacco user, but these results argue that health systems should be included as an integral component of a comprehensive tobacco intervention strategy. The HVMA results also give us an indication of the potential health impacts when meaningful use core tobacco measures are widely adopted. (27)In New York, four community health centers reported a significant increase in referrals to a state-based quitline using a fax referral program compared to usual care. Two comparison sites offered usual care (expanded vital sign chart stamp that prompted providers to ask about tobacco use, advise smokers to quit, assess readiness, and offer assistance (4As)) and two intervention sites received the chart stamp plus an office-based Fax referral link to the New York State Quitline. Adherence to the 4As increased significantly over time in the intervention sites with no change in the comparison sites. Intervention sites were 2.4 (p < .008) times more likely to provide referrals to the state Quitline over time than the comparison sites and 1.8 (p < .001) times more likely to offer medication counseling and/or a prescription. (28) One of the few controlled trials to determine effective methods to increase provider’s use of referral mechanisms was conducted in Wisconsin. When the Fax to Quit program started in 2003, only about 20 percent of tobacco-using patients contacted by the program signed up for quitline services. By July 2011, that figure reached approximately 55%. Although satisfaction with quitline services was not significantly different in quitline users referred by providers under the Fax to Quit program (96.8%), compared to those simply told about the quitline by their provider (92.2%); satisfaction with the quitline coach averaged 98.6% among Fax to Quit participants, slightly above the 93.7% rate in the comparison group. (P<.05) Also, 91% of Fax to Quit participants felt their healthcare professional was helpful in the decision to try quitting, well above the 77.5% of those in the comparison group. (P<.05) 96.1% of those referred under Fax to Quit made a serious attempt to quit tobacco use, compared to 83.2% of those in the comparison group. Those referred under Fax to Quit also had higher 30-day abstinence rates (46.8% versus 32.7%, P<.05) at 3 months after receiving services. (29)Another Wisconsin study found that enhanced academic detailing by regional outreach workers, including on-site training, technical assistance, and performance feedback, increased the number of referrals more than fivefold over a fax referral program implemented without such enhanced academic detailing. Participants from 49 primary care clinics in southeastern Wisconsin were randomized to one of two intervention conditions; the control Fax to Quit–Only (F2Q-Only) or the experimental condition Fax to Quit plus Enhanced Academic Detailing (F2Q_EAD). Clinic- and clinician-specif?c referral and quality referral rates (those resulting in quitline enrollment) were measured for 13 months post-intervention, starting in March 2009. The mean number of post-intervention referrals per clinician to the Wisconsin Tobacco Quitline was 5.6 times greater for F2Q_EAD (8.5, SD=7.0) compared to F2Q-Only (1.6, SD=3.6, p<0.001). The F2Q_EAD (4.8, SD=4.1) condition produced a greater mean number of quality referrals/clinician than did the F2Q-Only (0.86, SD=1.8, p<0.001) condition. (30) The benefit of an academic detailing adjuvant was also suggested by another non-experimental fax referral evaluation; the Bronx BREATHES program showed that an intensive set of academic detailing activities produced a 2.5-fold increase in the referrals of Bronx smokers to their state quitline over rates seen for other New York smokers. (23) Washington State implemented an academic detailing outreach program from 2008 to 2010 with online tools to increase routine identification and treatment of tobacco users. 629 unique health care organizations and 3,989 unique health professionals received services. Between 2007 and 2010, the ratio of health professional "How Heard Abouts" to total Quit Line registrations increased by 142.6% and 95.4% in Initial and Expanded Outreach Counties, whereas Never Outreach Counties showed an 11.2% increase. Fax referrals to the Quit Line increased by 132% and 232% in Initial and Expanded Outreach Counties versus a decline of 39% in Never Outreach Counties. (31) In another Washington State study, a case-based online CME/CE program, Refer2Quit (R2Q), was developed. R2Q includes quitline education and intervention and referral skills training tailored to a mix of provider types (e.g. physician, nurse, dental provider, pharmacist) and work settings (e.g. emergency, outpatient, inpatient) in four health care organizations A module teaching motivational enhancement strategies was also included. Sites that participated in the study increased the fax referral rates (OR 2.86, CI 1.52-6.00) as well as rates of referrals that converted to actual quitline registrations (OR 2.73, CI 1.0-7.4). Providers who completed the training expressed more positive attitudes and improved self-efficacy for delivering tobacco services. At follow-up, most providers reported increased delivery of tobacco interventions and QL referrals, although only 17% reported increased rates of fax referral. (32)North Carolina evaluated the effectiveness of a small-scale educational and promotional campaign to increase healthcare providers’ awareness and utilization of the state quitline fax referral service. The campaign included a direct mailing of fax referral promotional materials to 6,197 healthcare providers in North Carolina. An 8 month follow-up survey was mailed to a 10% random sample of providers who were sent the mailing. Valid surveys were returned by 271 providers (response rate?=?46%). Forty-four percent of respondents remembered receiving the mailing, and 40% reported familiarity with the fax referral service. While only 3.5% of respondents reported referring a patient to the quitline using the fax referral service in the previous 6 months, almost one-third reported an intention to use the fax referral service in the future. (33)Another mechanism tested to increase direct referrals is incentivization. Blue Cross and Blue Shield of Minnesota provided a minimum $5000 performance bonus to intervention clinics of a randomized controlled trial that referred at least 50 smokers for a 10 month period in 2005-2006. Pay-for-performance clinics referred 11.4% of smokers [95% CI 8.0%-14.9%] compared with 4.2% [95% CI 1.5-6.9%] for usual care clinics (P=.001), with differences in referral rates found in clinics with a history of being engaged or less engaged with quality improvement. Rates were similar in clinics with a history of being very engaged. The rate of patient contact after referral was 60.2% and among those contacted, 49.4% enrolled in services, representing 27.0% of the referred patients. The marginal cost per additional quitline enrollee was $300. Smokers were eligible if they stated readiness to quit within 30 days. The study design could not differentiate the separate effects of clinic incentivization and personalized physician feedback, both provided to intervention clinics. (34)Independent of referring patients to tobacco treatment programs, there is evidence that the electronic health record can prompt providers to deliver cessation treatment in primary care. A study in Wisconsin involving 18 primary care clinics found a higher percentage of patients (78.4% versus 71.6%, P<.001) had tobacco use status identified after EHR prompts to medical assistants to identify smokers and to clinicians to deliver a brief cessation intervention (medication and quitline referral). (35) An Oregon study evaluated the impact of EHR-generated practice feedback on rates of referral to the Oregon quitline. Intervention clinics received provider-specific monthly feedback reports generated from EHR data. The reports rated provider performance in asking, advising, assessing, and assisting with tobacco cessation compared with a clinic average and an achievable benchmark of care. During 12 months of follow-up, EHR-documented rates of advising, assessing, and assisting were significantly improved in the intervention clinics compared with the control clinics (p<.001). A higher case-mix index and presence of a clinic champion were associated with higher rates of referral to the state quitline. (36) In a pair matched group randomized study in 10 Houston family practice clinics, a new approach—Ask-Advise-Connect (AAC)—designed to address barriers to linking smokers with treatment was evaluated. Five clinics were randomized to the intervention and 5 to the control conditions. In both conditions, clinic staff were trained to assess and record the smoking status of all patients at all visits in the electronic health record, and smokers were given brief advice to quit. In the intervention clinics, the names and telephone numbers of smokers who agreed to be connected were sent electronically through the research investigator to the quitline daily, and patients were called proactively by the quitline within 48 hours. In the control clinics, smokers were offered a quitline referral card and encouraged to call on their own. Impact was based on the RE-AIM (Reach, Efficacy, Adoption, Implementation, and Maintenance) conceptual framework and defined as the proportion of all identified smokers who enrolled in treatment. In the intervention clinics, 7.8% of all identified smokers enrolled in treatment versus 0.6% in the control clinics (t4=9.19 [P<.001]; OR 11.60 [95% CI 5.53-24.32]), a 13-fold increase in the proportion of smokers enrolling in treatment. No quit outcome data was reported and no information was collected on demographics, including motivation to quit. (37)SECTION SIX: RECOMMENDATIONS FOR QUITLINE OPERATIONAL AND QUALITY STANDARDS FOR REFERRAL SYSTEMS The majority of these recommendations are most applicable to clinical providers and healthcare systems. They are not intended to minimize the importance of indirect referrals from all types of providers.REFERRAL PROCESSESAdopt referral processes that fit into existing referral workflows for providersDetermine predominant method of referral: verbal, fax or electronicDescribe benefits and drawbacks of brief referrals vs. fax referrals. Assume different workflows will be required for inpatients vs. outpatientsPromote processes that minimize time required of physicians and assistants. Encourage involvement of the entire healthcare team or organizational staff in tobacco use assessment and tobacco cessation efforts to maximize efficiency and promote sustainabilityDetermine who will provide the cessation intervention – providers or non-providers. Note reimbursement implications below. Use non-providers (e.g., medical assistants, LPNs, respiratory therapists, dental hygienists) where possibleBuild tobacco use screening into vital signsComplete all or part of the referral form (fax or electronic)Consider training non-providers to conduct brief motivational interviewing intervention and generate provider referral on behalf of provider Agree upon patients eligible for referral: limit to those in preparation or include those in contemplation?Emphasize state quitlines as a triage resource for providersQuitlines routinely route callers to the most appropriate cessation resource based on eligibility, insurance coverage, geography, and patient demographicsProviders can focus on the intervention and not eligibility requirements.Review reimbursement options for cessation counseling with provider, and determine whether provider will bill Medicare/Medicaid for coaching services.If yes, provider (e.g., physician, PA, NP) must conduct cessation counseling of greater than 3 minutes. Work with providers’ billing service to set up billing codes and workflows.Refer to Medicare billing instructions for providers.Determine Medicaid coverage for specific state, and refer to billing instructions providersIf no, non-provider may conduct tobacco cessation intervention (such as a brief session of motivational interviewing) Simplify and standardize quitline referral forms to minimize implementation barriers for providers and administrative processing barriers for quitline service providersInclude only the minimum information required to contact a patientInclude provider information (hospital or clinic, individual provider) required to provide feedback reportsFor example, minimize handwriting- and use preprinted patient labels to provide accurate, legible patient contact information for fax referral forms Seek opportunities to update providers on latest in pharmacotherapy, particularly changes in NRT labeling, use of combined NRT, and NRT dosing to addiction level and elapsed time. Avoid common quitline practices that can serve as barriers to provider referrals:Eliminate requirement that patient consent be documented before being referred to quitline (can be optional data element)Request but do not require physician consent for NRT on referral forms- (can be optional data elementDon’t require providers to go outside the EMR to make eReferrals (i.e., no “quitline only” sitesFor eReferrals, avoid any customization that require a “one-off” implementation by EMR vendorsAdopt standard eReferral forms and feedback letters as recommended by NAQC workgroupEliminates barriers to implementation for providers and EMRsReduces costs to state quitlines and quitline service vendorsPromotes creation of a “national clearinghouse” for eReferralsSupports ability of state quitlines to change service vendorsFor quitlines, maintain a variety of methods for sending and receiving protected health information (PHI) with providers and other referral sources.Use a crawl (manual), walk (hybrid), run (fully electronic) approach that allows both providers and quitlines to gradually develop eReferral capabilitiesSupports referral sources without an EHR.REPORTINGReferral forms should contain the following data elements (fax and electronic) Refer to the NAQC eReferral workgroup for suggested required vs. optional fields and additional technical details:Patient demographic informationPatient contact informationBest time and day to callProvider/clinic contact informationNRT authorizationReferral should contain the minimum data set required to initiate a referral call from the quitline. Additional data important to quitline funders is collected during the intake and enrollment process.Feedback reports should contain the following data elements (fax and electronic).Refer to the NAQC eReferral workgroup for suggested required vs. optional fields and additional technical details:Patient identifying informationEnrollment status (e.g., accepted, declined)Program status (e.g., active, ineligible, disengaged)Disposition (e.g., web only, multi-call) NRT status and dosingOutcomes (if available)Feedback reports should contain the minimum data set that providers would like to see included as discrete data in their EHR systems. Do not include send back information that is already in the EHR, such as gender. Quitlines and their service vendors may elect to send back letters or aggregrate reports (see below) to providers, but these are not included in the proposed standards.Recommended timing and content of feedback reports to providersWhen a fax referral is received or is invalidAt the time a patient enrolls in coachingIf a patient is unreachable or declines enrollmentWhen medications are ordered for a participantWhen a patient completes the programWhen a patient disenrolls for any reasonWhen patient outcomes data is availableDevelop better methods for reporting quit outcomes to providersConsider use of reports that meet provider needs for interim progress Refer to NAQC paper on how to increase response rates. For example consider a hybrid of phone and online survey methods.Integrate independent evaluator outcomes survey results with quitline case management system to facilitate reporting of both utilization and outcome dataCreate a standard dropdown list of referral sources to enable tracking across quitlinesSuggest sample reports at aggregate level for providers and quitline clientsSummary Report – by Institutional Provider: number of referrals received by hospital/clinic for current month and year to date, with disposition of referrals (e.g., accepted service, declined services, ineligible, unreachable). Useful for determining success of outreach efforts to area providers and for identifying opportunities for public/private partnerships.Summary Report – by Individual Provider: number of referrals received by individual clinician for current month and year to date, with disposition of referrals (e.g., accepted service, declined services, unreachable). Useful for tracking effectiveness of in-service efforts to individual providers and for assessing performance against quality improvement measures for tobacco cessation.Detailed Report: referral status by patient, including provider name and clinic, patient name and demographics, and insurance information. Useful for determining status by individual patient, available to authorized users of PHI.SYSTEMS CHANGEPrepare partners for successful systems changeBegin by getting buy-in at the leadership level of the organization.Identify a champion who will provide project management (this person is typicall not a clinician). Extend outreach efforts beyond traditional health care providers and provide ongoing technical assistance and client promotional materialsExamples include low income dental clinics, senior housing, county health departmentsEncourage participation of groups that work with members of priority communities that suffer from tobacco related disparities (e.g. CDC’s six funded priority community networks) and persons with behavioral health/substance abuse concerns. Also, encourage outreach to persons in quitline underserved populations (men, youth, etc.). Support NAQC initiatives to include quitline referrals as part of Stage III meaningful useTie into existing initiatives for health information exchange in your state/regionInitiate outreach efforts with large health systems in your communitySeek out tobacco cessation resources within the systemLink to providers’ existing priorities, such as complying with meaningful use incentives and clinical quality measures Seek out any ACOs that are operational or in development in your stateConsider creating state public/private partnership programs for sustainabilityState health plans, universities, employer groups, and business groups on health are frequent partnersReach out to state hospital associations, state and local medical societies, and state quality improvement organizations to assess interest in partnering on tobacco cessation as a clinical quality improvement initiative. Quitline funders that use a quitline service vendor should ask for assistance in marketing to private partners. Ask for help with proposals, pricing and cost-benefit analysis, marketing materials, presentations and other outreach efforts. Quitline service vendors should have the capability to provide separate agreements, invoicing and reporting to each state partnerDevelop promotional materials to help partners promote both brief referrals and provider referrals.Follow lessons learned for detailing and technical assistance (see body of report). EREFERRAL TECHNOLOGYSupport NAQC initiatives to adopt national standards for referral systems and health data exchange. Don’t recreate the wheel.Seek HIE solutions that don’t require point to point or custom software programming by providers / EHR vendorsThe biggest barrier to implanting eReferral systems is limited capacity of provider IT departments to make “one-off” changesWork with your quitline service vendor or quitline IT department to delineate responsibility for build out of the eReferral system:The quitline service vendor or IT department should be responsible for implementing the following eReferral components:Standard documentsInterface engineUser authenticationSecure file exchangeQuitline funders should focus on state-specific eReferral components, such as identifying existing HIE initiatives, finding out who the major EMR and HIE vendors are, and reaching out to hospital. Don’t spend valuable state funds building a “one-off” state system.Focus on eReferral components that are state specific, such as learning about existing HIE initiativesCreate a priority list of hospital/physician groups for implementation of eReferral systemsInitiate collaboration early on to get on their IT project list?SECTION SEVEN: REFERRAL SYSTEMS’ POTENTIAL FOR INTEGRATING QUITLINES INTO HEALTHCARE To be completed.References1. Centers for Disease Control and Prevention. Current cigarette smoking among adults aged 18 years—United States. MMWR Morb Mortal Wkly Rep. 2011;60(35):1207-1212.2. Canadian Tobacco Use Monitoring Survey (CTUMS) accessed at . Centers for Disease Control and Prevention (CDC). Quitting smoking among adults--United States, 2001-2010. MMWR Morb Mortal Wkly Rep. 2011;60(44):1513-1519.4. North American Quitline Consortium. All quitline facts: an overview of the 4 2011 annual survey of quitlines. Accessed at . Fiore MC, Goplerud E, Schroeder SA. The Joint Commission’s new tobacco-cessation measures—will hospitals do the right thing? N Engl J Med. 2012;366(13):1172-4.6. Fiore MC, Jaen CR, Baker TB, et al. Treating tobacco use and dependence: 2008 update. Rockville, MD: Public Health Service, 2008. 7. Conroy MB, Majchrzak NE, Regan S, Caroline B. Silverman CB, Schneider LI, Rigotti NA. The association between patient-reported receipt of tobacco intervention at a primary care visit and smokers’ satisfaction with their health care. HYPERLINK "" \o "Nicotine & tobacco research : official journal of the Society for Research on Nicotine and Tobacco."Nicotine Tob Res 2005;7(S1):S29-34.Jamal A, et al. Tobacco Use Screening and Counseling During Physician Office Visits Among Adults—National Ambulatory Medical Care Survey and National Health Interview Survey, United States, 2005–2009. Use of Selected Clinical Preventive Services Among Adults—United States, 2007–2010. MMWR Morb Mortal Wkly Rep. 2012;61:38.9. Smoking Cessation Leadership Center: 30 Seconds. Accessed at 10. Personal Communication – Christopher Anderson. Program Director, California Smokers’ Helpline. 11. Redmond LA, Adsit R, Kobinsky KH, Theobald W, Fiore MC. A decade of experience promoting the clinical treatment of tobacco dependence in Wisconsin. WMJ 2010;109(2):71–8. 12. Warner DD, Land TG, Rodgers AB, Keithly L. Integrating Tobacco Cessation Quitlines Into Health Care Massachusetts, 2002-2011 Prev Chronic Dis. 2012;9. 12.13. CMS Letter to State Medicaid Directors. June 24, 2011. Accessed at (2).pdf14. Tobacco-Use Cessation Counseling Services. Accessed at . Meaningful Use and Tobacco Cessation. UW-CTRI December 2012. CMS EHR Incentive Programs: Office of the National Coordinator for Health Information Technology: Accessed at 16. Centers for Disease Control and Prevention (CDC). Million Hearts: Strategies to Reduce the Prevalence of Leading Cardiovascular Disease Risk Factors --- United States, 2011;60(36):1248-1251.17. NCQA Patient Centered Medical Home. Accessed at . NCQA Disease Management Performance Measures. Accessed at . ActionToQuit Interview. American Academy of Family Physicians Office Champions Tobacco Cessation National Dissemination Project. March 19, 2013. Accessed at . North American Quitline Consortium. Online resources available at . Accessed April 2013. 21. Institute of Medicine. Ending the Tobacco Problem: A Blueprint for the Nation. Washington, DC: The National Academies Press; 2007.22. Schroeder SA . How Clinicians Can Help Smokers to Quit JAMA 2012; 308(15):1586-1587.23. Bernstein SL, Jearld S, Prasad D, Bax P, Bauer U. Rapid implementation of a smokers’ quitline fax referral service in an urban area. J Health Care Poor Underserved 2009;20(1):55–63.24. Personal communication, Rob Adsit. Director of Education and Outreach. University of Wisconsin School of Medicine and Public Health Center for Tobacco Research and Intervention25. Centers for Disease Control and Prevention. Current Vital Signs: Current Cigarette Smoking Among Adults Aged ≥18 Years with Mental Illness — United States, 2009–2011. MMWR Morb Mortal Wkly Rep. 2013;62(05):81-87.26. Multi-state Collaborative for Health Systems Change Webinar. Nov 8, 2012. Electronic Referrals: Quitlines and Beyond The Case for Generalized Clinic-Community Referrals with Feedback. Accessed at. Land TG, Rigotti NA, Levy DE, Schilling T, Warner D, et al. (2012) The Effect of Systematic Clinical Interventions with Cigarette Smokers on Quit Status and the Rates of Smoking-Related Primary Care Office Visits. PLoS ONE 7(7): e41649. doi:10.1371/journal.pone.0041649.28. Shelley D, Cantrell J. The effect of linking community health centers to a state-level smoker’s quitline on rates of cessation assistance. BMC Health Serv Res 2010;10:25.29. Kobinksy KH, Redmond LA, Smith SS, Yepassis-Zembrou PL, Fiore MC. The Wisconsin Tobacco Quit Line’s Fax to Quit program: participant satisfaction and effectiveness. WMJ 2010;109(2):79–84.30. Sheffer, M., Baker, T., Fraser, D., Adsit, R., McAfee, T., & Fiore, M. Fax referrals, academic detailing, and tobacco quitline use: a randomized trial. American Journal Of Preventive Medicine 2012;42(1):21–28.31. Schauer GL, Thompson JR, Zbikowski SM. Results from an outreach program for health systems change in tobacco cessation. Health Promot Pract. 2012; 13(5): 657-65.? 32. Carpenter K, Carlini B, Painter I, Mikko, AT, Stoner SA. Refer2Quit: impact of web-based skills training on tobacco interventions and quitline referrals. Journal of Continuing Education in the Health Professions 2012;32(3):187-95. 33. Mathew M, Shah V, Wild E, Goldstein A, Kramer K. Evaluation of a campaign to increase quitline fax referral service utilization. APHA Annual Meeting, Washington D.C., November 7, 2007. 34. An LC, Bluhm JH, Foldes SS, Alesci NL, Klatt CM, Center BA, Nersesian WS, Larson ME, Ahluwalia JS, Manley MW. A randomized trial of a pay-for-performance program targeting clinician referral to a state tobacco quitline. Archives of Internal Medicine 2008;168(18):1993–1999. 35. Lindholm C, Adsit R, Bain P, Reber PM, Brein T, Redmond L, Smith SS, Fiore MC. A demonstration project for using the electronic health record to identify and treat tobacco users. WMJ 2010 Dec;109(6):335-40.36. Bentz CJ, Bayley KB, Bonin KE, Fleming L, Hollis JF, Hunt JS, LeBlanc B, McAfee T, Payne N , Siemienczuk J. Provider Feedback to Improve 5A's Tobacco Cessation in Primary Care: A Cluster Randomized Clinical Trial Nicotine Tob Res (2007) 9(3): 341-349.37. Vidrine JI, Shete,S, Cao Y, Greisinge A, Harmonson, P, Sharp, B, Miles L, Zbikowski SM, Wetter DW. Ask-Advise-Connect: A New Approach to Smoking Treatment Delivery in Health Care Settings. JAMA Intern Med Published Online February 25, 2013.Appendix AGlossary of TermsAcademic DetailingNon-commercial based educational outreach to establish and improve programsAuthorized UserAny person whom is authorized by a covered entity or a business associate to create, access, send or receive PHI.Business AssociateAny person or organization with whom a covered entity shares PHI as required to perform a service (e.g., billing, contract labor). Covered entities must have a business associate agreement (BAA) in place before sharing PHI with a business associate or risk monetary penalties. HIPAA regulations apply to covered entities and business associates. Case Management System (CMS)A software system and database used by quitlines to record information about each participant and to administer administrative functions of the quitline. The case management system typically records patient demographics, quit dates, coaching calls scheduled, coaching call notes and results, quit rates, etc, and generates reports useful to quitlines.Covered EntityA hospital, physician practice, health plan, state quitline, or any other provider that generates and transmits PHI. HIPAA regulations apply to covered entities and business associates.CMSCenters for Medicare and Medicaid Services. An agency within the US Department of Health & Human Services responsible for administration of key federal health care programs. With the passage of the HITECH Act, the CMS has been charged with several key tasks for advancing health IT, including the implementation of electronic health record (EHR) incentive programs, a definition for the meaningful use of certified EHR technology, the drafting of standards for the certification of EHR technology and the updating of health information privacy and security regulations under HIPAA. Much of this work is being done in conjunction with the ONC. DataDistinct pieces of information usually formatted in a special way. The term is sometimes used to distinguish machine-readable from human-readable information. Discrete DataData that is distinct and separate (e.g., patient date of birth or phone number. In electronic files, denotes a data field that can be imported or exported separately from all other fields. Text and data files may contain discrete data, whereas image files do not.EHRElectronic Health Record, also known as an Electronic Medical Record (EMR). A computerized medical record designed to replace the traditional paper chart in a provider setting. Feedback ReportA report that informs a referring provider of the status and outcome of a patient referred to a quitline for tobacco cessation services.FileA collection of data or information that has a name, called the filename, and is stored in a computer. There are many different types of files, which are also referred to as file formats: text files (e.g., DOC), image files (e.g., PDF, JPEG), data files (e.g., XLS), and so on. Different types of files store different types of information.HIEHealth Information Exchange. Both a verb and a noun to describe the electronic sharing of health-related information among organizations:the electronic sharing of health-related information among organizations, or an organization that provides services to enable the electronic sharing of health-related information.HIPAAHealth Insurance Portability and Accountability Act. A US law designed to provide privacy standards to protect patients' medical records and other PHI provided to covered entities. HIPAA provides patients with access to their medical records and control over how their PHI is used and disclosed, and represents a uniform, federal floor of privacy protections for security and privacy.IntakeThe process of screening for eligibility and registering a caller for quitline services, or referring to other cessation services as appropriate.Meaningful UseAn incentive program available to hospitals and eligible professionals (i.e., individual providers) that can demonstrate meaningful use of a certified EHR, as measured by performance on a set of core and elective measures.NHINNationwide Health Information Network. A set of standards, services and policies that enable secure exchange of PHI over the internet. NHIN is sponsored by the ONC, and has two key initiatives to promote electronic exchange: NHIN Connect and NHIN Direct. In order to be NHIN-compliant, a network or HIE must be certified that it meets the following security standards: 1) Authentication and Certificates; 2) Security; 3) Trusted Authority; 4) Delivery Protocols; 5) Standards; 6) Provider Directories.ONCOffice of the National Coordinator for Health Information Technology. A division of the U.S. Department of Health and Human Services, its focus is to coordinate nationwide efforts to support the adoption of health information technology and to promote electronic exchange of healthcare information nationwide.QuitlineTelephone-based tobacco cessation services that help tobacco users quit. Services offered by quitlines may include coaching and counseling, referrals, mailed materials, training to healthcare providers, web-based services and free medications such as nicotine replacement therapy (NRT).Quitline ClientAn entity that funds quitline services for a population of individuals, typically a state, health plan, healthcare organization, or employerQuitline FunderA public entity that provides free quitline services, typically using tobacco settlement or state health department funds. ParticipantAn individual who is receiving services from a quitline. (Quitline participants are not referred to as “patients”, as quitlines are not licensed healthcare providers.)PatientAn individual who is receiving services from a provider.PHIProtected Health Information. PHI is any individually identifiable health information that is created, transmitted, or maintained by a covered entity in any form (e.g., paper, fax, electronic) Predictive Dialer A software system that dials outbound calls to participants automatically, reducing the time and expense associated with unanswered calls. Calls answered by participants are immediately routed via the phone system to quitline staff for live answer.ProviderAn individual or institution that provides healthcare services to patients. Individual providers who often refer to quitlines include physicians, dentists, psychologists, physician assistants, and nurse practitioners. Institutional providers include hospitals, clinics, physician and dental offices. Provider DirectoryA central directory with contact information (e.g., provider name, practice or hospital name, address, email, fax number, phone number) for all users on a secure health information exchange. A provider directory is an “address book” that is used to deliver PHI over a secure networkReferral FormA form that is filled out and sent by a referring provider to initiate a patient referral; typically includes patient demographics and contact information, reason for the referral, physician/clinic contact information, and authorizing signature.SFTPSecure File Transfer Protocol. SFTP is a secure method for sending files from one entity to another, also known as point-to-point transfer. ................
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